Case Study: Advance Care Conversations

Not knowing a patient's wishes for end-of-life care can lead to expensive and sometimes unwanted medical interventions. Gundersen Health System is trying to change that, by embracing a conversation around end-of-life care that is not about dying.

Editor's note: This piece is excerpted from a full case study that is available as part of the June 4 event, HealthLeaders Media Live from Gundersen Health System. For more information, visit www. healthleadersmedia.com/live.

It is human nature to avoid difficult conversations about dying. We often simply don't know what to say. Given the intimate nature of these discussions, they also require a lot of trust. That is why hospitals, health systems, and physicians have done a generally poor job of initiating meaningful, timely conversations with patients and their families about the difficult issues surrounding care in the final years of life.

In healthcare macroeconomic terms, a 2012 Wall Street Journal analysis found that Medicare spent 22.3% of its total annual hospital expenditures on the 6.6% of seniors (1.6 million) who died in one year. A major contributor to that expense is not knowing a patient's wishes for care, which can lead to often expensive and sometimes unwanted tests, procedures, and other interventions.

In smaller, more human terms, not knowing a patient's wishes for his or her end-of-life care can create heartbreaking choices for the family, says Jeff Thompson, MD, CEO of La Crosse, Wis.–based Gundersen Health System.

"You want something that's draining for the staff and family? Be at the bedside of an 80-year-old person who has been in declining health and now has a stroke and can't talk," Thompson says. "Now the family is saying, 'I wish I knew what she wanted.' The medical staff and the nurses are saying, 'I wish we knew what she wanted.' Nobody knows what she wanted. She didn't say. No one had the conversation and now people are just guessing. That's hard on staff. That's hard on the family."

Gundersen has succeeded in changing the mind-set of those in its own health system and the surrounding community by embracing a conversation around end-of-life care that is not about dying.

"Of course we're all going to die. We're not going to escape that," Thompson says. "But these conversations are about how are you going to live, and do you want to have a say in how you're going to live."